Aren’t all mammograms free because of the Affordable Care Act?

SUMMARY: So where’s my free mammogram? Aren’t all mammograms free because of he Affordable Care Act? Well, actually, it’s more complicated than that.

Some mammograms are covered completely, by either the company or by the insurer. Yet a lot of people are paying themselves. This is true for various reasons, as we learned somewhat to our surprise during our project with the Brian Lehrer show on WNYC crowdsourcing the price of mammograms. (We will be posting about the results of our survey over the next week or so.)

The experts at the National Women’s Law Center write: “Health plans are required to cover, without copayments, the preventive services recommended by the United States Preventive Services Task Force (USPSTF), including annual mammograms for women age 40 and over. This provision took effect in September 2010. … ‘Grandfathered’ plans — those that existed before the Affordable Care Act was passed — are exempt from this requirement, but plans will lose their grandfathered status if they significantly cut benefits, increase out-of-pocket spending, or change insurance carriers.” Here’s a fact sheet. The American Cancer Society also has this page of resources for breast cancer screening, including a state-by-state list of laws.

The picture we got of people assuming their mammograms were covered, and finding that they aren’t, raised questions: Many might have been under “grandfathered” plans, while others might be paying when they don’t need to. Some of the mammograms our contributors shared about took place over the past year or so, as the Affordable Care Act has gradually been coming into effect. We don’t know all the circumstances of everybody’s plan, so we can’t say definitively that everybody who paid shouldn’t have.

Also the costs varied widely (more later, and here’s a big shoutout of thanks to everyone who shared info: You. Are. Awesome.)

What to Do If You Think You Shouldn’t Be Charged

So do you think you are being charged when you shouldn’t be? What should you do? This article by the (NWLC) is a good guide — it refers specifically to contraceptives, but you could use similar wording for mammogram coverage.

For many people who shared their information, their mammograms were fully covered.

“My provider does not accept insurance, however, my insurance plan covers 100% of annual mammogram cost for women over 40.”

“I’m a self-employed Texan where health insurance is ridiculous: I’m stuck with an independent PPO policy with a $11,500 deductible. However I paid $0 because it was covered, I think because of Obamacare. Yay Obama!”

For many people, it was not covered at all, or only partially covered.

Here’s one, a charge of $380 and a negotiated rate of $170.37: “According to my Statement of Benefits, my insurance company did not pay any of this — I had to pay all of the negotiated price out of my pocket ([insurer] put it toward my deductible). I thought that routine mammos were supposed to be covered 100% under the ACA…”

“Because I have to meet my deductible, none of the cost was covered.”

“My insurance would pay but I rarely meet the deductible and she’s not in network.”

Meanwhile, we heard a lot from women who chose to pay for their mammograms themselves because they trust their out-of-network providers. More about that in another post.

So You Got Called Back for a Re-do: What to Do?

We heard from people who got a routine mammogram, and then were told after they left that they needed to come back and get an ultrasound, or even to get another mammogram. (Our friend who wrote a mini-three-part-series about this, here, here and here, is one such person.)

“I had a second mammogram on Apr 20, 13 as they needed to re-evaluate certain areas. The charges were $408 and member plan rate was $205.49.All was covered by the insurance I didn’t pay anything for the additional one. Couple of years ago, we had another insurance company and they had me pay the member rate fully as they didn’t accept the additional imaging!! this year I was lucky!”

“The radiologists at this clinic do not look at the mammogram until after the appointment. This year something was not clear so I had to return to have part of the mammogram redone. This redo cost me $366 out of pocket because it was no longer the routine annual screening (which is covered without a deductible). Will find a radiologist who will look at the results while I am still in the office for the next time around.” Charged: $623. Paid: 416.14.

Not everybody thinks this is an innocent mistake. Casey Quinlan, a media strategist and author of “Cancer for Christmas” and herself a breast cancer survivor, wrote in an email:

“My advice to any woman scheduling a mammogram: work ONLY with facilities who read the scans during your appointment. Why this isn’t SOP everywhere isn’t clear to me, other than they didn’t get the memo about patient-centered medicine. What is clear is that women can wind up paying for a second scan, days later, if there’s something the radiologist wants another/better/clearer look at. That could indeed be a revenue-generating move on the part of some imaging centers.

“I’ve only worked with imaging facilities where the scans are read immediately, and have been lucky enough to find two locally (Richmond VA) where I get to see the films, too. The downside is that I was able to diagnose my own cancer, simultaneously with my doctor, back in ’07 – but that was most definitely a win! The cost for my diagnostic bilateral – in the latest technology: 3D – at my center in Richmond VA is $250. I self-pay, since I’m uninsured, and this is the top mammography center in my area. That’s another win, in my book.”

The A.C.A. supposedly covers all screening mammograms. But once the mammogram is considered a diagnostic mammogram — when the radiologist is perhaps looking for evidence of cancer, a woman has a symptom, has had a history of potential problems, or is having a re-do of a routine mammogram, quite often the patient no longer falls under preventive services, and thus the procedure may not be covered.

There are also state-by-state variations. For example, Connecticut covers ultrasounds if recommended under certain circumstances. Rhode Island “requires individual and group insurers to provide coverage for 2 screening mammograms per year for women who have been treated for breast cancer within the past 5 years or who are at high risk for developing cancer due to genetic predisposition, have a high-risk lesion from a prior biopsy or atypical ductal hyperplasia),” the ACS Web site says, adding that in Wyoming, “the health plan is responsible only up to $250 for all cancer screenings.”

Screening is routine, the standard test, but a diagnostic procedure is on a more heightened alert. The script might go “we think there could be something here, so pay close attention.” The charge is higher. Sometimes also women were charged for both a mammogram and a sonogram, and received no insurance payment or only partial payment.

This was a typical comment: “Provider does not accept insurance reimbursement. Insurance (United Healthcare/Oxford) allows a maximum reimbursement of $222.75, but since we had not met our $9,000 out of network deductible, I received no reimbursement.”

“I pay the provider directly ($850.) This is for a mammogram AND a sonogram.

The insurance company covers $294 of this fee with a reimbursement check.”

Options for Those Who Are Uninsured

If you’re uninsured and qualify for low-income services, here are some options (we’ll add a separate, longer version of this in a couple of days).

“The Avon foundation offers FREE cancer screening for women with no insurance. They are associated with Columbia Presbyterian Hospital. Women can get their standard mammograms and Pap smears and I believe they also offer free prostate exams for men. I used me for my first 3 mammograms in NYC and when I had a lump and needed a sonogram and biopsy I was not changed for that either. It’s an incredible service for the low income uninsured.”

Women’s Outreach Network: “Free – if you have insurance they will bill them, but you won’t ever see a bill. It’s a mobil mammogram unit that parks in different places around the city. 631-581-4171 Let’s hope they still exist.”

And two other suggestions: People who are uninsured increasingly are negotiating prices for procedures before having them, paying cash. This is true not just for mammograms, but for other procedures as well. Here’s our list of mammogram prices in the New York area. You can find similar lists for other cities; just search.

And, to close, two of our favorite stories from the women who contributed their price information.

Here’s one: “Called to find out the cost since I don’t currently have health insurance. Was quoted $194. I can afford this and won’t have to wait until I do in fact have coverage.”

And this: “I was given a quote of $1,200 minimum for a mammogram at [provider No. 1]. [Provider No. 2] would not even put me on the schedule if I was paying out of pocket (“only Medicaid and Medicare). So for less half the price of a mammogram at [Provider No. 1], I bought a plane ticket to Kansas, rented a car, and had my mammogram on the same brand-new equipment they use at [Provider No. 1]. Ridiculous.”

5. Women’s health resources. No one should ever have to go without a mammogram or other women’s health issues. Reproductive health belongs to us. Here are some resources, and some thoughts about women’s health.